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r <br /> TANK CLOSURE CERTIFICATION FORM <br /> Pyr 1 a 1 <br /> BUSINESS NAME l FAVUWIOt <br /> Airport Way Lube <br /> SME A00RESS tree <br /> 442 N. Airport Way <br /> BUSINESS CITY 105 aUSINESS LP 106 <br /> Stockton , CA <br /> TANK OWNER NAME S60 <br /> Don and Celia Nathe <br /> TANK OWNER AOORESS wi <br /> 1632 Oxford Way <br /> TANK CIWNER CITY 501 STATE SO0 DP SM <br /> Stockton. <br /> Tank a Flammable Vapor Oxygen <br /> (State Tank IDS,if applicable) Top Center Bottom Top Center Bottom <br /> Tank Interior <br /> Atmosphere <br /> Readings See previous closure plan <br /> III CPRTIFIrATION <br /> On examination of the tank,I cerci a nk is vis IT rodud,sludge.scale(thin,flaky residual of tank contents),anseate and debris. I further certify <br /> that the information provided he in a and a rat o m est of my knowledge. <br /> CERTIFIER SIGNATURESTATUS OR AFFILIATION OF CERTIFYING PERSON Sas <br /> CERTIFIER NAME(PRI Richard O e Certifier is a representative of the CUPA/LIA: YES ❑ NO ❑,', <br /> CERTIFIER TITLE SOT <br /> Contractor Name of CUPAILIA <br /> ADDRESSP.O. Box 357 If cartifier iS other than CUPA/LIA check appropriate box below: <br /> CITY Lodi CA 95241-0357 ❑ Certified Industrial Hygienist(CIH) <br /> PHONE (209)368-6175 <br /> DATE CERTIFIED Ste CERTIFICATION TIME ❑ Certified Safety Professional(CSP) <br /> 12/98 ❑ Certified Marine Chemist(CMC) <br /> ❑ Registered Environmental Health Specialist(RENS) <br /> ❑ Professional Engineer(PEI <br /> ❑ Class 11 Registered Environmental Assessor <br /> CSLS licensed contractor(with hazardous substance certificate) <br /> ❑Yes V No This tank previously hell flammable or combustible materials. If yes,the tank interior atmosphere shag be re-checked wdh a combustible gas <br /> indicator prior to work being conducted on the tank. <br /> Cartifiefs tank management instructions for scrap dealer,disposal facility,etc: <br /> A copy of this certificate shall accompany the tank to the recyding/disposal facility. <br />